Health Facility Availability

The region has the total of 291 working health facilities that consists of 246 Dispensaries, 31 health centers and 14 hospitals. Of the 246 dispensaries in the region, 200 dispensaries are owned by the government, 22 owned by Faith Based Organizations, 8 by parastatals and 16 are owned by private entities. Whereas of the 31 Health centre 24 health centres are owned by Government, 6 by Faith Based Organizations and 1 is owned by private entity,. As for the 14 hospital, 2 Hospitals are owned by Government, 11 by Faith Based Organizations and 1 by private entity. It should be acknowledged that 65 health facilities out of 246 health facilities are non Government owned demonstrating good public private partnership especially with 6 district designated hospitals in the region.

Dispensaries

In Kagera region there are a total of 640 villages and 66 streets in the 8 district councils. However, only 246 (38%) functioning dispensaries exist. This demonstrated a shortage of dispensaries by 62%. New Dispensaries are planned to be constructed and most of them are expected to be operational by June 2014. Karagwe DC have planned to construct six new dispensary of (kahanga, Omulusimbi,Chonyonyo,Kigarama, Kanoni and kandegesho), while Muleba DC have planned to construct two dispensaries (Kabale B and Bisheke dispensary), Biharamulo DC have planned for two dispensaries ( Nyambale and Mkumkwa ), Ngara DC have planned for six new dispensaries (Kasange, mukikomelo, Ntenrungwe and Ibuga) will be completed and operational by March 2014. On the other hand the rest of two dispensaries from Ngara (Murulama,and Kumtana) will be completed and operational by June 2014. Missenyi DC have planned for two new dispensaries of (Mwemage and Buchurago), Bukoba MC have planned to construct new dispensary of (Nyanga), Bukoba DC have planned to construct 4 new dispensaries of (Kazinga, Buguruka, Mugajware and Bituntu) and Kyerwa have planned four new dispensaries of (Rukulaijo,Khinda,Karongo and Kigorogoro) all of which will be completed and operational by March 2014. Regarding, physical states of health facilities and condition's of essential infrastructure such as water and electricity the current situation show that o ut of 246 functioning dispensaries 167(66 %) dispensaries have source of water and power. 79 (39%) dispensaries have no access to water and power. 33 (13%) dispensaries require repairs. In Kyerwa DC 30% of dispensaries and Ngara DC 29% of facilities are without power supply and source of water where as coverage in Bukoba MC is 100%. Efforts are made both at the regional and council to address the prevailing situation. In total 27 dispensaries are in plans of being constructed that will increase the access by 4% however more emphasis is needed to construct more dispensaries to meet the ruling party election manifesto through MMAM

Health Centers

In Kagera region there are a total of 181 wards. However, only 31 (17%) functioning health centres exist. This demonstrated a shortage of Health centre by 83%. It should be noted that the number of Health centres have decreased from 33 health centres to 31 health centres from the previous year because two health centre from chato district shifted to Geita region. With the shortage of health centres, some of the districts have planned for upgrading the dispensaries. Karagwe DC have planned for upgrading (Kijumbula dispensaries), Ngara DC have planned for upgrading (Nyakisasa dispensary), Missenyi DC have planned for upgrading 2 dispensaries of (Kashenye and Kilimilile).

Therefore upgrading a total of 4 dispensaries to be a new health centres will relieve shortage by 2%. With regards to access to power and water all health centre have access to power either through the grid or by solar energy that were install through the support of the development partner however, access to water is limited to only 70% of health centres. It anticipated that the remaining 30% of health centres will have access to water as some of the districts have the issue addressed in their plan. However there is a need to initiate new health centres or upgrade dispensaries to health centres to meet the current ruling party manifesto requirement and the RHMT are closely working with the councils to achieve their targets

Hospitals in the Region

There are a total of 14 hospitals in the region of which 11 hospitals ( 79%) are owned by FBOs, 2 hospitals (14%)are Government owned and 1 hospital is privately owned . However, Muleba DC and Bukoba MC are constructing a new hospital. Bukoba DC have planned for upgrading (Kishanje health center), Ngara DC have planned for expanding Nyamiaga hospital , and Kyerwa DC have planned for constructing a new District hospital, while currently using the Nkwenda Health Center as the council Hospital. This demonstrates the vast availability of hospitals in the region that have strong linkages, coordination and cooperation between government, faith based and private institutions.

The ongoing construction of two hospitals in Bukoba MC and Muleba DC and upgrading of one health centre to hospital will increase coverage of Districts hospitals from the current one hospital (13%) to four hospitals (50%). As to the physical infrastructure, access to water and power all hospitals have the basic infrastructure and 100% access to water and power. However, almost all hospitals need to improve on their infrastructure to accommodate for emergency medicine, public private partnership and emerging programs such as MC, cervical cancer screening, maternal and newborn under one roof and so forth. Nevertheless the increase in number of hospitals will improve quality of service and referral system within districts and the region as whole.

Socio cultural Information

Social cultural information is based on cultural activities and phenomenon such as male circumcision, cervical screening, education, women empowerment and gender equality, most vulnerable children, water access, refugees, and latrinization. Nevertheless it is acknowledged that different tribes with their respective ethnicity, cultures and beliefs reside in the region which can influence the uptake of different health interventions.

Male circumcision (MC):

Conventionally the community in Kagera region is a non-circumcising except for Muslims and the minority urban population. However, since the evidence of suggesting the importance of MC in prevention of HIV infection, the region has managed to circumcise a total of 70,957 male clients from September 2009 to December 2013. The services were made available and accessible through health promotion and campaigns MC has been widely accepted and number of males circumcised had been constantly increasing thus contributing in prevention of HIV and AIDS. Furthermore, MC services are also provided in 7 health facilities which serve as static site. The region is expecting to circumcised additional 42,000 clients and expand the number of static sites to 10 in 2014 so as enhance the efforts of HIV and AIDS prevention through MC.

Latrinization:

Total latrine coverage for the region has increased from 55% in 2011, 57% in 2012 to 65% in 2013. This increase is contributed by the National sanitation campaign. The number of improved latrine increased by 10,235 latrines from 246,108 latrines in 2012 to 256,343 latrines in 2013. At the same time there is a decrease of temporary latrines from 48,247 to 38,012 this implies that it is 21.2% of temporarily latrines have now become improved latrines. Similarly, the number of households with no latrine has decreased from 45% (2011) to 35% (2013) due to community awareness and enforcement of the law. This implies that the risk of community exposure to diarrhoeal diseases and worms infestations has decreased.

Highlight of Health trends and Issues in the Region.

The paragraphs below describe the health trends and major issues within Kagera regions in order of their priorities in the region. These health trends were identified and prioritized after understating the current situation in the councils so that necessary support is provided to the councils.

Maternal and Newborn Health:

In the last three years there is a decreasing trend of maternal mortality rates (MMR). MMR has decreased from 107.9/100,000 live births in 2010 to 82.6/100,000 live births in 2012. However, in 2013 there is an increase from 82.6/ 100,000 live births to 121/100,000 live births. Factors contributing towards increase in MMR despite trainings such as Life saving skills (LSS), BeMONC, Focused Antenatal Care (FANC) and improved supply of commodities and equipment include late reporting of pregnant women to the facilities, inadequate Individual Birth Preparedness (IBP), inadequate referral system, inadequate use of partogram and shortage of skilled health care providers. This significant increase of MMR in 2013 has hampered efforts of achieving the reduction in MMR by ¾ of 77.3/100,000 live births to achieve the Millennium Development Goal. (MDG). It should be noted that data from the community might have not been captured in this report accordingly and still remains a challenge as the system for community data is not well established.

NMR, IMR and under five mortality rates have all shown an increasing trend in the last three year. Although, they are lower than the national rate but the quality and reliability of data from the districts is still a challenge. Furthermore, community system of collecting data for neonatal and infant deaths is still weak and needs more support and to be integrated with Local Government Monitoring Database (LGMD) and Health Management Information system (HMIS). Efforts are required to prevent deaths amongst under fives to achieve the MDG 4

HIV and AIDS:

A decreasing trend of HIV prevalence in clients who were counseled and tested through HIV testing and counseling (HTC) services was observed in the last three years. The HIV prevalence trend was 8.3% in 2011, 6.3 % in 2012 and 7.8 in 2013 . Although a decrease in programmatic prevalence is seen, the community prevalence has increased from 3.4% ( DHS 2007-2008) to 4.8% (THMIS 2012). It should be acknowledged that the number of clients tested are higher than the number of clients enrolled in care and treatment clinic. Considering the community prevalence of 4.8% it is expected that 117,984 PLHIV are residing in the region however those enrolled in care by December 2013 are only 45,791(39%) clients. Similar decreasing trends of HIV prevalence are also observed in pregnant mothers in the last three years (3.4% in 2011 and 2.5% in 2012 to 2.6 % in 2013). In addition, there is a remarkable decrease in the prevalence of HIV in HIV Exposed infants (HEI) from 10 % in 2010 to 7.0% in 2013 due to scale up of PMTCT services that aims at virtual elimination of mother to child transmission.

The programmatic HIV prevalence among HTC clients in the region was initially decreasing from 9.2% in 2010, 8.3% in 2011 and 6.3% in 2012. Although the trend showed a decrease in prevalence it was thought to be a virtual decrease because the number of clients tested through HTC have been decreasing from 78,804 in 2010 to 51,208 in 2012 which is only 65% of those tested in 2010 due to shortage of HIV testing kits. However, in 2013 the prevalence showed an upward trend to 7.8%. This is also in line with the Tanzania HIV and Malaria Indicator Survey (THMIS) that shows an increase in community prevalence from 3.4% (THMIS, 2008) to 4.8% (THMIS, 2012). The probable factors contributing towards an increase in both programmatic and community prevalence are thought to be an increase in testing, improved diagnostic facilities, stable HIV infected population because of care and treatment services including ART and decreasing emphasis on community awareness in regards to prevention. It should be acknowledged that although there is an increase in number of people enrolled in care, there are still more than 61 % of PLHIV (72, 194clients) who have not been enrolled in CTCs according to the HIV prevalence of 4.8%. If the programmatic prevalence of 7.8 % is utilized than only 28% of PLHIV are enrolled in care thus demonstrating a large number of PLHIV in the community who have not accessed services. In order to address the accessibility issue the RHMT together with CHMT are currently assessing new CTC sites for service delivery. It should be noted that the current tools capture HIV prevalence by combining both the PITC and VCT data to provide a combined HIV testing and counseling (HTC) data. Therefore, it was not possible to segregate data for PITC and VCT in this plan. Nevertheless the region shall make initiatives to gather these data for the next plan in accordance to the tables in the new planning guide.

HIV prevalence amongst pregnant women in the last three years is also decreasing, 3.4% in 2011 and 2.5% in 2012 to 2.6 % in 2013. All districts have shown a decreasing trend with exception of Karagwe which showed a slight increase of HIV prevalence among pregnant women from 2.0% in 2012 to 2.7% in 2013 which is attributed to improved documentation at the district level. . In addition, there is a remarkable decrease in the prevalence of HIV in HIV Exposed infants (HEI) from 10 % in 2010 to 7.0% in 2013. All districts have reported a decrease in the prevalence of HEI except Missenyi DC. Nevertheless is expected that HIV prevalence in HEI will further decrease because Kagera Region is among the 6 Regions in Tanzania mainland which have started with the implementation of PMTCT Option B+ since November 2013 that aims at virtual elimination of mother to child transmission. Most of service providers are trained so that they can provide the comprehensive service in the community region. However, major challenges towards elimination of HIV infection in PMTCT include issues of poor disclosure so poor uptake of the ART, late arrival at the facility (third trimester) for delivery, influx of infected client from neighboring countries

Tuberculosis (TB)

99% of TB patient were tested for HIV in 2013. Testing for HIV amongst TB patients has improved because of availability of test kits However, the prevalence of HIV among TB patient increased from 36.7% in 2010 to 40% in 2012 and 2013 . This high percentage of clients with TB/HIV co infection calls for comprehensive care. In addition foci of TB patients have been seen areas of borders and shores of lake Victoria in the district of Missenyi, Karagwe and Muleba

The percentage of tuberculosis treated successfully has increased from 95% in 2011 to 98% in 2013. All eight districts have demonstrated the increase. This has been attributed to improved skills of HCW in correctly diagnosing TB and accessibility to diagnostic test for TB. Similarly the TB cases cure rate has also increased from 94% in 2011 to 98% in 2013 with all districts showing the same trend. This high cure rate has been achieved because of the Direct Observed Therapy (DOT) modality of treatment that is being used throughout the region. Due to TB/HIV co-infection all TB patients are tested for HIV. In 2011 100% of TB clients were tested for HIV. However, in 2011 only 40% of TB patient received HIV testing due to shortage and frequent stock out of HIV test kits. Nevertheless, 99% of TB patient were tested in 2013. This is a remarkable achievement however efforts are made to achieve 100% through ensuring constant commodity supply in the region.

Vaccination Coverage:

In 2013, the immunization coverage for DTP-HB3 (92.7%) and for children under one vaccinated for measles (93.7%) in the region has surpassed the national target of 90% in comparison to the year 2011 and 2012. However, the emphasis lies in maintaining the achieved coverage .

Malaria:

There is significant increase in the total number of malaria cases both in under five years and over five years from 96,277 cases in 2011to 234,992 cases in 2013 for under fives and 81,913 cases in 2011 to143,658 cases in 2013 for over five years. Consequently the proportion of laboratory confirmed malaria cases among both under five years and above five years has been dramatically increasing from 5.4 to 9.4 and 9.7 to 9.9 respectively. This is also in line with an increase of Proportion of total laboratory confirmed malaria cases from 20% in 2012 to 36% in 2013. The main contributing factors to the increase in malaria in the region are: Improper use of LLINs, decrease in herd immunity due to extensive IRS that decreased the malaria prevalence in the community causing rebound malaria and presence of resistant strains. However, there might be also virtual increase in malaria as the data might be duplicated with double reporting of diagnosed and laboratory confirmed cases. Therefore, RHMT and CHMT are coordinating with community partners to enhance community awareness through community change agents and school health programs to increase use of LLNIs, environmental sanitation and early seeking for diagnosis and treatment of malaria. Furthermore, RHMT shall ensure availability of mRDT test kits and ALU for diagnosis and treatment of Malaria.

Leprosy

The region is illustrating a decrease in leprosy notification from 45 patients in 2011 to 35 in 2013. This decrease could be regarded as a result fewer leprosy cases in the community. Alternatively it could also be a result of inadequate diagnosis of leprosy cases. Biharamulo DC has the highest reported leprosy cases because of sentinel hot spots for leprosy clients. The region is promoting the use of case definition of leprosy patient for correct diagnosis and treatment.

Substance abuse users

The number of substance abuse users in the region has been increasing from 161 (2011) to 466 (2013). The increasing trend can mainly be accounted to the fact that there has been a general awareness to the substance abuse issue and reporting rates from the district councils has increased over the previous years. Furthermore the substance of abuse could also be implied by ease in availability and accessibility of substance of abuse and awareness of support services at health facilities. The region borders with four countries of which results into easy illegal entry of substance of abuse especially from Kenya, Uganda, Rwanda and Burundi. The common substance of abuse which are illegally imported from neighbouring countries are Khat (Mirungi), Cannabis (bhangi), Kuber (ugoro) and brewed spirits. Other drugs such as Heroin and Cocaine are rarely consumed due to high price which results into low affordability by users.

Biharamulo and Karagwe (plus Kyerwa) are the top most Districts in the substance of abuse due to the reason that their soil condition is highly supporting growing of Cannabis. Other Districts have less reported cases due to low level of awareness, social-cultural reasons and low peer pressure. Currently, the reported cases for Kyerwa District Council are not available since this is a newly formed council (July 2013) in which the DMHCO has not yet been appointed. However, sensitization is highly needed to all District Mental Health Coordinators to conduct supportive supervision on health facilities as scheduled and to ensure all cases on substance abuse are adequately reported Therefore the RHMT will continuously emphasize on awareness rising and work closely with CHMTs to minimise the use substance of abuse and promote health care seeking behaviour for the users.

Child Health Indicators

Regional Neonatal Mortality (NMR) rates has an increasing trend from 3.2 in 2011 to 5.1 in 2013. However in comparison to the national rate of 25, Kagera region is demonstrating a lower NMR. It should be noted that although the region is reporting a lower NMR the data lack information on the deaths that have occurred in the community. No reporting from the community is thought to be due to cultural beliefs and inadequate system of collecting data from the community. Most districts are showing an increasing trend except Ngara Dc is almost stable. Bukoba MC and Muleba DC in 2013 have shown a decrease or almost the same NMR as of 201 where as Biharamulo DC, Bukoba DC , Missenyi DC and Karagwe DC have shown an increase in NMR in the last three years. This increase is related to lack of resuscitation equipment and inadequate life saving skills and supportive supervision among health care providers. The decrease in NMR in Muleba (3 .94, in 2011, 6.6 in 2012 and 4.0 in 2013) is attributed to strong emphasis in neonatal care after a two fold increase in 2012, regular supportive supervision, outreach services and mentoring. The increase in Bukoba DC and decrease in Bukoba MC are through to be due to improved data management in segregating the deaths according to the districts whereby previously they were accumulated in Bukoba MC. Nevertheless a lot of efforts in term of neonatal care and delivery of resuscitation equipments in the regional hospital could also signify the decrease in Bukoba MC. RHMT is continuously following up on the neonatal care through regular supervision and is currently advocating to improve acquisition of data from the community with support from village/ community health care workers and home based care providers.

Infant Mortality Rate (IMR) in the region has increase from 6.4 in 2011 to 8.4 in 2013. Three district Biharamulo DC, Bukoba MC and Muleba have shown a decrease in IMR from 2011 to 2013 where as the rest of the district have shown a remarkable increase in IMR. The overall increase is though to be due to late reporting, frequent malaria and inadequate knowledge of diagnosis and management of malaria. While the decrease in trend in the above mention districts is attributed to majors such as environmental sanitation campaign, Indoor residual spraying and active search and case management of malaria after the outbreak that occurred in June 2013 in which RHMT played an important role of coordination of partners and supply of commodities including bed nets.

Under five Mortality Rate have shown an increasing trend in the region from 9.2 in 2011 to 14 in 2013. Biharamulo, Bukoba DC Muleba and Missenyi have shown a decrease in under five mortality 14.3, 16.4, 10.8 and 22.7 in 2011 to 8.0, 7.1, 7 and 20.0 in 2013 respectively. However when compared to 2012 -2013 All district have illustrated an increase in under five mortality rate except Biharamulo which had same rate as the previous year and Bukoba DC which had a decrease from 12.0 in 2012 to 7.1 in 2013. The overall increase was attributed to the malaria outbreak in the region which called for National attention. Following the outbreak several measure were put in place that lead to avoid future outbreaks including thresholds for malaria surveillance especially in Muleba. Furthermore, late reporting to the facility and inadequate management of malaria also contributed to a lot of under five mortality in the region.

Overall the NMR, IMR and under five mortality rate have all shown an increasing trend in the last three year. Although, they are lower than the national rate but the quality and reliability of data from the districts is still a challenge and it appears that the whole process of collecting, compilation, analysis and utilization of data at the district level is inadequate. Furthermore, community system of collecting data for neonatal and infant deaths is still weak and needs more support and to be integrated with Local Government Monitoring Database (LGMD) and Health Management Information system (HMIS). The RHMT is planning to conduct RMSS-C and mentorship to CHMTs quarterly and shall discuss the accuracy and validity of these data in these visits. Furthermore, data validation and harmonization will be done during RHMT/CHMT stakeholders meetings and quarterly review of data at the CHMT and RHMT level.

In 2013, the immunization coverage for DTP-HB3 (92.7%) and for children under one vaccinated for measles (93.7%) in the region has surpassed the national target of 90% in comparison to the year 2011 and 2012. However, districts such as Bukoba DC have persistently shown a decreasing trend in the last three years (DTP HB3 coverage 87.6% in 2011, 81% in 2012, 61.6% in 2013 and Measles 89.5% in 2011, 91.4% in 2012, 62.4% in 2013). Some of the factors contributing to the low immunization coverage in Bukoba DC are lack of CHMT supervision, poor performance in outreach services, vast nature of the district and the ill health of the coordinator for over 2years. It should be noted that measles immunization coverage in Bukoba DC had reach 91.4% in 2012 because of National Immunization Day (NID). Similarly, Ngara DC has been performing below the National target for both the DTP- HB3 and Measles which is also attributed to lack of supervision although there was an issue of the target population that was projected to be higher because of the presence of the refugees which was not later adjusted after the return of the refugees though in 2012 the coverage was above the National Target due to NID. Nevertheless, Missenyi DC, Muleba DC, Biharamulo DC and Karagwe have demonstrated have a remarkable increase in their immunization coverage because some of the factors such as lack of transport (Missenyi Dc and Muleba DC), inadequate supervision and follow up were addressed by both RHMT and National.

Vitamin A coverage in the region is above the national target however, it has dropped its coverage from 96.5% in 2011 to 92.5%. Moreover, Biharamulo DC has been showing a decreasing coverage of Vitamin A from 96.4% in 2011 to 85% in 2013. Possible reasons for this declining trend are poor sensitization for Vitamin A, bureaucratic procedures in release of funds, mobile small mining settlements, immigrants and hard to reach areas. Through RMSS-C RHMT has advocated to the DED towards measure to be taken to increase vitamin A coverage.

There is a significant increase of severe malnutrition rate amongst children in the region. The trends have increased by four fold from 0.39% in 2011 to 1.7% in 2013. Furthermore, all districts have shown an increase in severe malnutrition rate. Factors contributing to malnutrition include climatic changes leading to low production of food, low knowledge in children feeding in Ngara community despite having a lot of produce which is utilized for preparing local brews and trade with neighbouring country. In addition, Ngara community practise polygamy where by one man can have 6-8 wives who bear many children from young ages and children are responsibilities of women and male participation in child upbringing is very low. Moreover, with improvement in road network and transportation coupled with demand from other regions and neighbouring countries due to low production and political instability in these countries a lot of food crops from the region are exported leading to inadequate food availability in the region. The increase in severe malnutrition could also be attributed to improve reporting. Nevertheless, the RHMT shall ensure districts have budgeted community sensitization on food and nutrition for children and improved on documentation.

Maternal Health Indicators

The Regional maternal mortality rate (MMR) had been previously decreasing as observed from 107.9/100,000 live births in 2010 to 82.6/100,000 live births in 2012. However, in 2013 there is an increase from 82.6/ 100,000 live births to 121/100,000 live births. MMR trend has increased amongst the majority of Districts like Missenyi DC, Biharamulo DC, Karagwe DC, Ngara DC, and Bukoba DC. Factors contributing towards increase in MMR despite trainings such as Life saving skills (LSS), BeMONC, Focused Antenatal Care (FANC) and improved supply of commodities and equipment include late reporting of pregnant women to the facilities, inadequate Individual Birth Preparedness (IBP), inadequate referral system, inadequate use of partogram and shortage of skilled health care providers . However, Bukoba Municipal and Muleba DC have managed to decrease their MMR through follow ups, mentoring, regular supportive supervision, increased male involvement, improved referral system, trainings in FANC, and LSS. It should also be acknowledged that the decrease in MMR noted in Bukoba MC and the increase in MMR noted in Bukoba DC is due to improved quality of data reporting, documentation and follow up of maternal death whereby, maternal deaths from Bukoba DC that have occurred at Regional Referral Hospital are being recorded and accounted in Bukoba DC instead of previously being double counted and reported in Bukoba municipal. With the current increase in MMR the region is far behind in reducing the MMR by ¾ to achieve the Millennium Development Goal (MDG). RHMT is regularly conducting maternal audit and follow up of maternal death which is planned in their annual plan however, more emphasis is needed to strengthen the referral system, follow up and mentoring of health care providers in the lower health facilities

The rate of births at health facilities and births attended by skilled attendants has decreased from 71.9% in 2011 to 62.1% in 2013 suggesting that the accessibility to health facilities, referral system from lower to higher health facilities and community sensitization on importance of delivering at health facility is still a challenge. Furthermore, inadequate gender empowerment for timely response to health facility deliveries results in more home deliveries. The system of individual birth plan has hindered most of pregnant women to deliver in the health facilities due to the additional burden of cost for buying new basin and mackintosh which are needed for the care. Payment for Performance (P4P) is also not efficiently practiced at the facility level that would motivate the heath care providers to respond and encourage health facility deliveries. Therefore, the RHMT need to advocate for funds solicitation to the Local Government Authorities to undertake P4P effectively. Community members also need to be sensitized on importance of health facility delivery where there are qualified health service providers for better services.

Moreover, additional support, close follow-up and mentorship are needed to the least performing districts such as Muleba DC(83% in 2012 to 58% in 2013) Bukoba DC (45 % in 2012- 17% in 2013) and Missenyi DC (77% in 2012 to 45 in 2013) with health facility deliveries below 50%. Some of the contributing factors in these poorly performing districts include unavailability of health care workers at the facility after normal working hours, inadequate supportive supervision and shortage of human resource for health On the other hand Karagwe has a significant increase in delivery at health facilities (from 46% in 2012 to 95% in 2013) attributed to availability of health care worker at the facility, presence of skilled staff, increase in facilities providing delivery services, improved supportive supervision which is evident through RMSS-C and close follow up of the trained staff.

The number of antenatal visit is one of the predictor that determines the progress of the pregnancy ultimately informing towards the progress made towards maternal and newborn health. The percentage of four or more antenatal visit is a new indicator therefore; the data to determine the trends from the district were not available. Nevertheless from the available data for 2013 only 25% of women attend all four antenatal visits much lower than the national target of 80%. Most women however have at least attended one antenatal visit. The RHMT will continue to put emphasis on the CHMT through RMSS-C and RMSS-H as well as advocate for the antenatal visits at the regional, district and community level in order to improve the maternal health.

Postnatal care in the region has showing a decreasing trend in last three years from 82.2% in 2011 to 78.4% in 2012 to 60% in 2013. With exception of Bukoba MC, which is an urban setting with the regional referral hospital all districts have shown a decreasing trend in post natal care. The decreasing trend is thought to be because of shortages in human resource for health and distance to the health facilities. In 2011, the reporting rate was higher because of intensive trainings and sensitization on post natal care. The RHMT has already started to follow up on maternal health due to increase in MMR through maternal audit meetings and follow of maternal and child health during supportive supervision.

There have been fluctuating trends for contraceptive prevalence rate in the region from 14.4 in 2011, to 20.1 in 2012 and to 17.4 in 2013. However, there was unavailability of some methods like implants, injectables and pills. Moreover, the IP had financial constraints between July to September 2013 leading to almost no family planning intervention being carried out in the region. In addition, fears on adverse effects and misconception on the use of contraceptives have also contributed to low acceptance rate. All the districts have demonstrated contraceptive coverage much below National target of 60%. Therefore, RHMT is coordinating with various partners and CHMTs to ensure availability of contraceptives and quality service delivery to the community and to deliver the right message to the community about contraceptive use to alleviate the misconceptions.

There is an overall increase in of trend of the percentage of IPTP 2 in the region from 51.7% in 2011 to 54.6% in 2013 although the individual districts demonstrate a fluctuating trend. Ngara DC has the highest coverage of IPT in the past three in comparison to other district (64.0% in 2011, 86.2% in 2012 and 78.0% in 2013). The highest coverage of IPT in Ngara DC is in line with the % of women attending all four antenatal visit, the percentage of women receiving postnatal care and the contraceptive acceptance rate all of these coverage are high in Ngara DC in comparison to the other district thus illustrating the commitment of the district towards maternal and newborn health. Similarly the coverage of IPT in Missenyi DC's has been increasing constantly from 69.0% in 2011 to 72% in 2013. However, Bukoba DC and Bukoba MC have shown a remarkable decrease IPT coverage of from 76.6% in 2012 to 36.0 in 2013 (Bukoba DC) and 52 of 2011 to 45 of 2013.(Bukoba MC) due frequent stock outs in the district. The overall irregular pattern of IPT coverage in the districts is attributed to irregular supply and distribution of SP and poor documentation in health facilities, and inadequate supportive supervision.

Blood safety

Trend of blood collection from relative replacement donors has decreased from 70% in 2012 to 36% in 2013 which resulted from effort and support from MOHSW who contracted Tanzania Red Cross Society (TRCS) to support blood safety in the region for the period of five years (2012-2017). Conversely, safe blood has been advocated throughout the Region to ensure blood is administered to patients after being properly screened at zonal blood bank.

There has been a decrease in blood demand target for the Region from 8,340 units in 2012 to 6,350 units in 2013. The decrease in demand is 24% amounting 1990units (RHMT baseline survey report, 2013). The decrease in demand could be directly associated with the official announcement of newly formed Regions, were as Chato became one among the councils which constitutes district councils of Geita Region. Furthermore, data shows a decline in anaemic cases especially among under-five and or improved and timely referral system of clients to higher levels. Complete data reporting on blood safety from all 14 transfusing health facilities in 2012 was maintained to date, though data collection and close follow up.

The overall blood collection in the year 2013 covers only 69% of demanded safe units this amount is still not meeting the actual requirement. Major constraint influencing failure to meet blood demand target for the region is inadequate community sensitization which limits the number of units being collected from voluntary non remunerated donors and sometimes limited resources to sustain uninterrupted operations of blood campaign and collection aiming at controlling stock out of blood at any point of time.